Demystifying the Health Care Claim Attachments The Eleventh National HIPAA Summit Washington DC Thursday September 8, 2005 Gary Beatty President EC Integrity, Inc.
Demystifying the Health Care Claim Attachments
The Eleventh National HIPAA SummitWashington DCThursday September 8, 2005
Gary BeattyPresidentEC Integrity, Inc.
PROVIDERS INSURANCE AND PAYERS SPONSORS
EligibilityVerification
Service Billing/Claim Submission
AccountsReceivable
Enrollment
Claim Acceptance
Accounts Payable
Enrollment
Claim Status Inquiries Adjudication
PretreatmentAuthorization and Referrals
Precertificationand
Adjudication
Enrollment
Payment Order
Elig. Inquiry
Elig. Response
Health Care Services Delivery
Claim
Patient Info.
Claim Status Inq.Patient Info.
Claim Status Rsp
Claim Payment
Claims Attachments - HIPAA
Electronic exchange of additional information to support the healthcare claim or encounter
HIPAA HIPAA legislation requires that the secretary of DHHS adopt a standard for attachments 30 months after enactment.Development work for claims attachment recommendation started in 1996Attachment workgroup within X12 and HL7 working closely with CMS and HHSProposed/Final Regulations
Attachment UsagesSupport Health Care Claims AdjudicationPrior Authorization AssessmentsValidate policies and standards are metPost payment reviewMitigate fraud and abuse
Goal of Health Care Claim AttachmentsMake the process of submitting and adjudicating health care claims more effective and efficient by providing a structured and standard means of requesting clinical/supporting data for health care claims or encounters
BenefitsReduced staffing/costsProviders:
Reduced amount of supported data exchanged Decrease days revenue outstandingBetter predictability to payer data content needs
Payers:More complete informationIncrease 1st pass adjudication
Early History of AttachmentsWEDI Attachment Workgroup Report, 1994 Recommendations:
Standardize attachment data elementsCoordinate affected entities to develop implementation guidesWork to standardize/eliminate attachmentsDevelop 274/275 as primary vehicleCreate standard way to link data across transaction sets
More History…Proof of Concept (POC) Team
5 Medicare contractors funded by HCFA to develop Electronic Request for Information1997 began considering options for Claims Attachments as response to request - April 1997 approached HL7August 1997 POC Team joined HL7 and helped to form the Attachment Special Interest Group (ASIG)ASIG solicited industry input before moving forward
History…Industry outreach recommendations
Determine most frequently used AttachmentsConsider Attachments where HL7 messages already exist / in developmentNeed to “Standardize” the questions payers ask - industry consensus requiredForm “Attachment workgroups” by soliciting help from all sectors of industry (e.g. payers, providers, National Associations)Use LOINC codes
History…Selection Criteria:Similar to the approach used to select the original HIPAA transactions:
Outreach to identify with subsequent review of available standards to select standard, if possibleIntegrate well with existing HIPAA standardsAdhere to the selection guidelines regarding: technology neutral, ANSI accredited, ultimately reduce admin cost
More history…Selection Results:
Standard for Claims Attachments did not existThe health care clinical information domain belonged to Health Level Seven (HL7)HL7 membership represents the expertise for clinical standards developmentHL7 is ANSI accredited, technology neutral
X12 Standards for Attachments
ASC X12N 277 Request for Additional Information (004050X150)ASC X12N 275 Additional Information in Support of a Health Care Claim or Encounter (004050X151)
HL7 Standard for AttachmentsClinical Document Architecture (CDA)
Provides flexibility for varying levels of implementation
Human Decision VariantScanned imageText data
Computer Decision VariantFull codified structured data using LOINC
What is LOINC?Logical Observation Identifier Names and Codes Universal names and ID codes for identifying
laboratory and clinical test results other information meaningful in claims attachments
FreewareOwned by
Regenstrief Institute http://www.regenstrief.org/
Logical Observation Identifier Names and Codes (LOINC) Committee
Why LOINC?1996 POC pilot revealed that Claim Status Reason Codes were not effective in requesting additional informationUsing LOINC allows for specific questions to be asked when neededLOINC already had many codes needed for Claims AttachmentsLOINC Committee was accommodating regarding special code requests
Business FlowSolicited Model
ASC X12N 837 Health Care Claim/Encounter
ASC X12N 277 Request for Additional Information
ASC X12N 275 + HL7 CDA Additional Information
ASC X12N 835 Remittance Advice
Business flow Unsolicited Model
ASC X12N 837 Health Care Claim/Encounterand ASC X12N 275 +HL7 CDA Additional Information
Payer sends ASC X12N 835 Remittance Advice
Structure of Attachments
A 277 asks forAttachments
orElements
A 275 sendsElements
consisting ofAnswer parts
Electronic Attachment
Element
Element
Element
Element
Element
–By sending LOINC
Element Answer Part
ElementAnswer Part
Answer Part
–Identified by LOINC
LOINC Question/Answer ExampleEmergency Department 18679-1
Question Answer Respiratory Rate Respiratory Rate18686-6 11291-2 85
Body Temp Body Temp18688-2 11289-6 101.6
Temp Reading Site11290-4 1 (oral)
Attachments1. Rehabilitative Services (9 disciplines)
1. alcohol/substance abuse2. Cardiac3. medical social services4. occupational therapy5. physical therapy6. Psychiatric7. respiratory8. Therapy9. skilled nursing and speech therapy
2. Emergency Department
Attachments3. Clinical Reports
Diagnostic imagingDischarge noteEcho heartEEG brainEKGElectromyelogramEndoscopyExercise stress test
AnesthesiaArthroscopyBronchoscopeCardiac catheterizationColonoscopyConsultation noteConsultation requestCytology
(Including, but not limited to)
Attachments
Procedure noteProgress noteRadiologySpirometrySurgical pathologyTemperature chart totalVisit note
Flexible sigmoidoscopyHistory and physicalNotesInitial assessmentNursingOB echoOperative notes
(Including, but not limited to)3. Clinical Reports (cont.)
Attachments4. Laboratory Services5. Ambulance6. Medications
Attachments in DevelopmentHome HealthDME Periodontal ChartingConsentChildren’s Preventive Health Services
CDA StructureCDA defines tag names and nesting<levelone>
<clinical_document_header>
<body>
</levelone>
</clinical_document_header>
</body>
Clinical Document Architecture (CDA) Structure
HeaderDocument InformationEncounter DataService Actors (such as providers)Service Targets (such as patients)Localization
BodySingle <non-xml> element - information on a external file that contains the bodyOne or more <section> elements
CDA StructureHeader
Document InformationDocument IdentificationDocument TimestampsDocument ConfidentialityDocument Relationships
CDA StructureHeader
Service Actors
People responsible for a clinical documentAuthenticatorsIntended recipientsOriginatorsTranscriptionistHealthcare providersOther service actors
CDA StructureHeader
Service TargetsPatientOriginating deviceOther significant participants (e.g. family members)
CDA StructureBody
Single <non-xml> element - information on a external file that contains the body (non-XML)One or more <section> elements
StructuresNested <section> elements<coded_entry> elements
CDA StructureBody <section>
Structures<paragraph><list><table>
Entries<content><coded_entry> <coded_entry.value><link> <link_html><observation_media><local_markup> Plain text
CDA
ASC X12N 275 (004050X151)Additional Information to Support a Health Care Claim or Encounter
275
ASC X12N 275 (004050X151)Additional Information to Support a Health Care Claim or Encounter
ST*275*000000001*004050X151~
SE*18*000000001~
::
::
BIN*55*<?xml version=“1.0”?><levelone…>….</levelone>~
GS*PI*SENDER CODE*RECEIVER CODE*19940331*0802*000000001*X*004050X151~
GE*1*000000001~
ISA*00*0123456789*00*1234567890*ZZ*SUBMITTERS ID*ZZ*RECEIVERS ID*930602*1253*^*00405*000000905*0*T*:~
IEA*1*000000905~
Attachment Data VariantsHuman-Decision Variant
Paper/image based health recordsTransmit scanned images or textXSL style sheet will be included
Computer-Decision VariantOriginal intent for claims attachmentsUses LOINC valuesAllows for automatic processing
Provider Paths to Compliance
Billing Application
275/Attachment(image)
Provider Paths to Compliance
Billing Application
275/Attachment(XML/CDA)
ConvertData into
CDA
Manual entry into
utility
XML/CDA
Provider Paths to Compliance
Billing Application
275/Attachment(XML/CDA)
Manual entry into
utility
Provider Paths to Compliance
Billing Application
275/Attachment(XML/CDA)
EHROr
OtherClinical App
XML/CDA
Payer Paths to Compliance
275/Attachment(image)
X12Translator
Adjudication/Remittance
Payer Paths to Compliance
275/Attachment(XML/CDA)
X12Translator
Adjudication/Remittance
AutoAdjudicate?
Yes
No
Payer Paths to Compliance
275/Attachment(XML/CDA)
X12Translator
Adjudication/Remittance
AutoAdjudicate?
Yes
NoCDA
Translator
Claims Attachment SuiteASC X12N 277 Request for Additional Information (004050X150)ASC X12N 275 Additional Information to Support a Health Care Claim or Encounter (004050X151)HL7 Additional Information Specification Implementation Guide Release 2.1 based on HL7 CDA Release 1.0Logical Observation Identifiers Names and Codes (LOINC)LOINC ModifiersAdditional Information Specifications CDA for Attachments R2.1 based on CDA R.1 (6 attachments)
HL7 Additional Information Specifications
AIS 0001: Ambulance Service Attachment (CDAR1AIS0001R021)AIS 0002: Emergency Department Attachment (CDAR1AIS0002R021)AIS 0003: Rehabilitation Services Attachment (CDAR1AIS0003R021)AIS 0004: Clinical Reports Attachment (CDAR1AIS0004R021)AIS 0005: Laboratory Results Attachment (CDAR1AIS0005R021)AIS 0006: Medications Attachment (CDAR1AIS0006R021)
www.ecintegrity.comwww.edipartners.comwww.x12.orgwww.hl7.orgwww.wpc-edi.com
Thank You